Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation and management of suspected CRBSI.
SOAP
Subjective (S):
Symptoms:
Inquire about any recent symptoms suggestive of infection, such as:
Fever
Chills
Rigors (shaking)
Malaise (general feeling of unwellness)
Redness or tenderness at the catheter insertion site
Explore for urinary symptoms that might indicate a concurrent urinary tract infection (UTI).
Catheter History:
Investigate the type of central venous catheter (CVC) and duration of placement.
Explore for any recent manipulations or changes to the catheter.
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying conditions that might increase susceptibility to CRBSI (e.g., diabetes, immunosuppression)
Recent hospitalization or surgeries requiring CVC placement
Previous episodes of CRBSI or other bloodstream infections
Objective (O):
Vital Signs:
Record temperature (including the presence of chills or rigors), heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam to assess for:
Signs of systemic inflammatory response syndrome (SIRS)
Catheter insertion site redness, swelling, or purulence
Peripheral stigmata of infection (e.g., Janeway lesions, Osler nodes)
Consider lung exam to assess for possible septic pulmonary emboli.
Laboratory Tests:
Report results of:
Blood cultures (obtained from peripheral and central line sites, if possible) with time to positivity.
Complete blood count (CBC) for white blood cell count and differential.
Other tests as indicated (e.g., inflammatory markers like C-reactive protein (CRP) or procalcitonin)
Assessment (A):
Clinical Diagnosis:
Based on clinical presentation, positive blood cultures, and presence of a central venous catheter, establish a high suspicion for CRBSI.
Note if fulfilling SIRS criteria for systemic inflammatory response.
Catheter-related:
Emphasize that the bloodstream infection is likely catheter-related based on the presence of a CVC.
Organism and Sensitivities:
If blood cultures are positive, identify the specific microorganism causing the CRBSI and its antibiotic sensitivities.
Plan (P):
Blood Culture Interpretation:
Correlate blood culture results from peripheral and central line sites (if obtained) to differentiate catheter colonization from true CRBSI.
Antibiotic Treatment:
Initiate broad-spectrum antibiotic therapy based on empiric guidelines while awaiting culture sensitivities.
Narrow antibiotic therapy once culture results and sensitivities are available.
Catheter Management:
Catheter removal: Depending on the severity of CRBSI and the ability to establish alternative vascular access, consider prompt removal of the CVC to eliminate the source of infection.
Catheter salvage (if applicable): If catheter removal is not feasible, emphasize the importance of aseptic technique during manipulation and meticulous catheter care to prevent further complications.
Supportive Care:
Provide supportive measures to manage hemodynamic instability and other symptoms associated with sepsis (if present).
Consider fluid resuscitation and vasopressor support as needed.
Re-evaluation:
Schedule close follow-up visits to monitor response to treatment, including repeat blood cultures to document clearance of infection.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., infectious disease)
Imaging studies performed (e.g., chest X-ray to evaluate for pneumonia as a potential source of sepsis)
Implementation of infection control measures to prevent further CRBSI spread
Patient education regarding the importance of catheter care and signs/symptoms of CRBSI
Discussion of long-term central line access needs and potential alternative options (if applicable)